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• August 8, 2016 Create Date
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Aviation Short Investigation Bulletin - Issue 9

The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are
accidents, serious incidents and incidents. It is from the information provided in these notifications that
the ATSB makes a decision on whether or not to investigate. While further information is sought in some
cases to assist in making those decisions, resource constraints dictate that a significant amount of
professional judgement needs to be exercised.

There are times when more detailed information about the circumstances of the occurrence would have
allowed the ATSB to make a more informed decision both about whether to investigate at all and, if so,
what necessary resources were required (investigation level). In addition, further publicly available
information on accidents and serious incidents would increase safety awareness in the industry and
enable improved research activities and analysis of safety trends, leading to more targeted safety
education.

To enable this, the Chief Commissioner has established a small team to manage and process these factual
investigations, the Short Investigation Team. The primary objective of the team is to undertake limited-
scope, fact-gathering investigations, which result in a short summary report. The summary report is a
compilation of the information the ATSB has gathered, sourced from individuals or organisations involved
in the occurrences, on the circumstances surrounding the occurrence and what safety action may have
been taken or identified as a result of the occurrence. In addition, the ATSB may include a SafetyMessage
that is directed to the broader aviation community.

The summary reports detailed herein were compiled from information provided to the ATSB by individuals
or organisations involved in an accident or serious incident.
AO-2011-091: VH-ZPA, Operational non-compliance